A client with massive ascites had a paracentesis. The site continues to leak through several layers of dressings, despite the nurse holding pressure. Which intervention should the nurse do first?
a. Call the physician and request the puncture site be sutured.
b. Have the client lie on the side with the puncture site.
c. Obtain a urostomy pouch and apply it at the puncture site.
d. Use a roll of Kerlex to hold the dressing in place.
C
Sometimes a pouch can be used to collect fluid draining from the paracentesis site if it is exces-sive. This allows the nurse to objectively measure the output and helps preserve the client's skin. This is an independent nursing action. In extreme cases, the physician can suture the puncture wound shut.
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